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Special Articles

U.S.A. VERSUS A.M.A.

THE great trial in which the American MedicalAssociation has to defend its attitude towards certainmethods of " group medical practice " is shown to bewell under way by an instalment (just received) of theverbatim report which the association is publishing in itsjournal.l Two counsel have made opening statementsfor the prosecution. The first has explained how theHome Owners Loan Corporation initiated the projectof Group Health Association, Inc., because H.O.L.C.(if we may adopt the convenient use of initials so welldeveloped in America) found that its borrowers neededso many loans to meet doctors’ bills, and thought thatan ampler and better medical service, preventive as wellas curative, could be furnished cooperatively throughG.H.A. The defendants include not only the A.M.A.but also the Medical Society of the District of Columbia-,the Harris County Medical Society, the WashingtonAcademy of Surgeons and 21 named individuals.Counsel alleged a conspiracy to prevent the 800 or moredoctors of the Medical Society of the District of Columbiafrom accepting employment with G.H.A., to obstructG.H.A. in its efforts to obtain doctors from practitionerswho were not members of the society, to attack doctorswho joined G.H.A. and to persuade them to abandon theconnexion under threat of professional discredit in theirpractices and in their hospital work, and lastly to induceall local private hospitals to join in the boycott ofG.H.A. by refusing to admit Group Health doctors tohospital privileges. A subcommittee of the A.M.A., itwas said, had reported that G.H.A. was unethical andthat participation in it by any member of the District ofColumbia Medical Society would make him liable todisciplinary action as well as deprive him of courtesyfacilities at various hospitals which the A.M.A. hadcoerced into the boycott.The additional opening statement by a second counsel

for the prosecution was mainly concerned with what,without any intended disrespect, might be called blue-book material. He outlined the general developmentsof preventive medicine, bacteriology, radium, cardio-

graphy and X-ray examination and dealt with the

report of the American expert Committee on the Cost ofMedical Care. His object was to show that families inthe lower income-groups receive too little medical serviceand find the cost of illness disastrous. This informationwas material to indicate that Group Health Associationand similar organisations improved the distribution ofmedical care and spread the cost by a system of periodicalpayments. The American College of Surgeons, saidcounsel, had recommended in 1934 the continuance ofexperiments with periodic prepayment plans becausethey gave hope of more adequate medical care for thelow-income groups. A week later the A.M.A. hadpassed a resolution condemning the college for itsrecommendations. The A.M.A. insisted that any suchplan should comply with its own general principles.One of these was that the plan should embrace all thequalified physicians within the locality ; anotherrequired the cost of medical service in any plan to beborne by the patient who could afford to pay at the timewhen it was rendered. The A.M.A., alleged counsel,was hostile to group practice on the prepayment basisand had gone beyond peaceful persuasion in its methods.

It may be convenient at this point to note that theseproceedings are criminal, not civil. There is an indict-tnent, running into 30 pages, alleging conspiracy andviolation of the so-called Sherman Anti-Trust Law.This statute, named after its sponsor John Sherman (theyounger brother of the famous general of the Civil War),was passed in 1890 and has since been modified. Notcontent to rely on the common-law doctrine which makesagreements " in restraint of trade " unenforceable, itprohibits under heavy penalties any contract, combina-tion or conspiracy which restrains trade or attempts toestablish monopoly. In England we should expect acase of this nature to be dealt with not by a criminalprosecution but by an application to a Chancery judge

1. J. Amer. med. Ass. 1941, 116, 601-630.

for an injunction and a declaration of the rights of theparties. Our classic authorities on the law of restraintof trade are mostly decisions in civil proceedings-theMogul Steamship case in 1892, the Maxim-Nordenfeldtcase in 1893, and the pronouncement by Mr. JusticeAstbury in the Firemen’s Union case in 1926 whichexercised no small influence upon the general strike.It is perhaps unnecessary to explain that the District ofColumbia is (like Canberra in Australia) a federal arealying outside the jurisdiction of the separate states. Itwas carved out of Maryland on the north and Virginia onthe south, and it accommodates the federal governmentof the whole country. There are in America manytowns called Washington ; this one is distinguished as" Washington, D.C."-Washington in the District ofColumbia. Its great and growing population is largelyofficial. The American law-courts are of two kinds-those belonging to the several states and those of thefederal government. In the latter class is the famousSupreme Court of the United States at Washingtonwhich says the last word upon all constitutional disputesand upon the validity of all legislation (whether state orfederal). The trial of the A.M.A. is proceeding atWashington in one of the district courts of the federalsystem. American forensic procedure often strikesEnglish observers as old-fashioned ; but the deliberateefforts to secure a jury which will eschew all bias aredoubtless necessary in this case where so many Washing-tonians may be members of G.H.A. or patients or friendsof the defendant doctors. The court has patientlyexamined all the prospective jurors to find out whetherthey are subject to any such influence and even whetherthey (or members of their families) are officials of theUnited States, the prosecutor. Jurors have been askedby the court if they or any members of their familieshave ever been sued by a physician, or if they have ever" had any occurrence which has aroused any antagonisticfeelings towards a doctor, a physician, or any group ofdoctors or physicians " ; had they formed any opinionabout the right of hospitals to select doctors for theirstaff, or about the right of doctors to organise themselvesin associations with rules and regulations governingprofessional practice ? And so on.To return to the trial, the two opening addresses for

the prosecution were followed by a spirited openingaddress by counsel for the defendants. He explainedthe constitution and standards of the A.M.A. ; itsformulated ethics were derived, he said, from an English-man named Thomas Percival who in 1803 framed themfor the College of Surgeons in the City of Manchester inEngland. The code, based on the oath of Hippocrates,had been proved to be the only safe standard for dis-tributing medical care to the public and the patient.The great developments in medicine, outlined by theprosecution, had been due to the efforts of the A.M.A. toprevent the destruction of progress by quacks andcharlatans who advertised their wares, in such languageas the G.H.A. was using-" You can’t sell medicalservice as you sell baked beans."

PLAN TO CHECK RHEUMATISM

RHEUMATIC disease, though widespread, painful,disabling and responsible for great economic loss, hasnever roused public sympathy or conscience as keenlyas tuberculosis, cancer or venereal disease. For onething it presents no clear-cut picture ; how can it, whenthe word has been used to cover at least two, andprobably more, distinct disease entities ? The acute andsubacute rheumatism of childhood, manifesting itselfas rheumatic fever, tonsillitis, chorea and growingpains and bringing in its train heart damage, invalidityand often death, has probably nothing in common withthe disabling muscular rheumatism, fibrositis or osteo-arthritis of later life ; and these again may prove to bedistinct from rheumatoid arthritis, and even from eachother. To devise a plan which will ensure the diagnosis,treatment and aftercare of all these is not simple, butLord Horder, in collaboration with the Empire Rheu-matism Council, has some practical suggestions to make.’Their plan was almost ready in 1939 but it seemed

1. Rheumatism: A Plan for National Action. London: H. K.Lewis. 2s.

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doubtful whether the time was then opportune topublish it ; now Lord Harder feels that

" considerationsof humanity, of national safety and true economy pleadfor some immediate effort to check rheumatic disease."What he has to say is addressed to all who are interestedin public health, and he writes without using unnecessaryscientific terms.

THE PUZZLE

In stating the extent of the problem he notes thatadults with rheumatism in England and Wales can beconservatively estimated at over a million, and theeconomic loss among insured workers at ;E17,000,000 ayear. Cases of juvenile rheumatic disease, calculatedon the basis of the statistics of the L.C.C. medicalservice, he puts at 200,000 in Great Britain.Our knowledge of the aetiology of rheumatic disorders

is still vague. Discussing possible factors in its causa-tion, Lord Horder shows how far our questions wereahead of our knowledge, and pleads on almost everypage for more research. In juvenile rheumatism wecan say that infection, bad housing and perhaps heredity,defective diet and scanty clothing play a part. Inadult rheumatic disorders occupations figure largely,especially those which invite small injuries, bruising,repetitive movements and cramped attitudes. Climate,of course, does its share : " the old man carries thealmanack in his bones." Other factors suspected of

contributing are focal sepsis, glandular dystrophy, someinherited or acquired biochemical flaw, diet, heredity,mental or emotional disturbance, housing, injury andgeological conditions. Against most of these can beset a question mark ; we do not know how much or howlittle they act as rheumatic provocants. Uniform record-keeping and a thorough study of cases should settle someof these questions ; others require intensive work in thelaboratory.

WHAT CAN BE DONE

Little as we know about the cause of diseases groupedunder the heading of rheumatism we can-contrary tocommon belief-do a good deal for them. Juvenilerheumatism presents a problem of its own, calling forearly diagnosis, determined treatment and steadyaftercare. For the chronic rheumatic diseases of adultsinuch can be done by physical treatment in its severalforms, massage, pyrotherapy and shock therapy, physicalexercises, drug therapy, orthopaedic measures, coloniclavage and vaccines. Lord Horder assesses the relativevalue of the various remedies cautiously but is able toquote figures from many treatment centres showing theexcellent results obtained by a judicious and persistentattack on the symptoms ; no claim is made that anytreatment now in use strikes at the unknown cause.At the Devonshire Royal Hospital 3062 patients were

admitted in 1937-38, of whom 2617 were discharged cured ormuch improved. At the Royal Mineral Water Hospital atBath 62% of patients were cured or relieved in the eighteenthcentury, 88% in the nineteenth, and 95% (so far) in thetwentieth. The British Red Cross Clinic, treating out-

patients only, claims that 60-3% of patients are freed fromobjective symptoms and 29% improved, leaving a balance of11%. An American treatment centre reports that 75% ofcases are cured or improved, 20% are refractory and 5%hopeless.

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This is an encouraging picture, suggesting that if wecan place appropriate treatment within reach of all whoneed it the practical problem is largely solved.

THE PLAN

Lord Horder suggests that this could be done bysetting up, on a regional basis, specialised treatmentcentres each of which would supervise a number of localcentres in its own area. The special centres woulddiagnose and treat both inpatients and outpatientsreferred by local treatment centres, hospitals or privatedoctors. Each special centre would be under thecharge of a whole-time permanent medical officer withspecial experience of rheumatic disease, and would bestaffed by qualified assistants, paid or voluntary,including workers in every branch of physical therapy,radiology, hydrology and chiropody. The centre wouldalso have access to a full consultant staff of physiciansand surgeons, including an orthopaedic and manipulativesurgeon, a dental surgeon, a gynaecologist, a rhino-

laryngologist, a pathologist and a radiologist. Ten tofifteen such centres, it is estimated, would be sufficientfor Great Britain.

Local treatment centres should of course be muchmore numerous, and would treat outpatients only, eachcentre being equipped to deal with anything from 50to 250 patients a day, depending on local needs. Thelocal centres would provide massage, remedial exercisesand the simpler heat and electrical treatments. Thestaff would be trained in massage, one of them havingin addition a qualification in hydrology, and one a fullnursing qualification. Patients would be received on therecommendation of their own doctor, remaining underhis treatment for everything except their rheumaticsymptoms. Is it, perhaps, questionable policy to dividethe patient up according to his diseases in this way ?In theory it seems unsound and though in practice itmight work out fairly well, it deserves careful pre-liminary consideration. The medical officer in chargeof a local treatment centre would not necessarily be onwhole-time service but might have charge of two orthree centres ; he should have special experience in thediagnosis and treatment of rheumatic disease. Throughclose liaison with the special treatment centres, con.

sultants would visit the local centres when their adviceis needed.One aim of the plan is to educate the patient in the

understanding and care of his own disease, and this willbe achieved at the special treatment centres, by lectures,and films, which will instruct him in the importance ofsuch things as diet, rest, clothing and exercises. It willeven be possible for some patients to carry on a simplecourse of treatment at home, thus avoiding frequentvisits to the local centres ; in this they will naturallyneed the supervision of skilled social workers. Thissystem has worked well as organised by the MayoClinic arthritis department.Another aim of the plan is to train sufficient medical

personnel in the diagnosis and care of rheumatism byarranging special postgraduate courses and lectures,not only for those who are staffing the clinics but forschool medical officers and any other doctors who areinterested. Some of the special centres, it is hoped,will be attached to university medical schools ; andthe medical staffs of all of them should be equal to theteaching task required of them.The plan will divide patients into three sections : a

large group who after a short period of institutionaltreatment and an educational course would be able tocarry on home treatment with periodic visits to a localcentre ; another large group who could attend regularlyat a treatment centre ; and a small group who wouldneed inpatient care or treatment which could only begiven at a special centre.The cost of the scheme would not be as great as

appears at first sight. The special centres would beaccommodated in existing hospitals, clinics and spaswhich could provide the necessary equipment ; thelocal centres could be housed in hospitals, pit-headbaths, public baths, welfare premises of factories or ifnecessary in huts put up for the purpose.The cost of treatment could be met in full by those

who could afford it, at a concession rate (for example,through the Hospital Saving Association) by those withless means, and by an extension of the National HealthInsurance’system for insured workers. At present thereare very few rheumatism treatment centres at whichapproved societies can arrange treatment for theirmembers, and it is scarcely just that a man in London orSheffield should have opportunities for treatment whichare denied to his fellow in some other part of the country.All contributors, as Lord Horder points out, should beon an equal footing. He sees no need for elaboratecentres or equipment, believing that research will shortlygive us fuller knowledge and thus more control of thediseases treated, and that early diagnosis and treatmentwill reduce the morbidity from rheumatism.

RHEUMATIC DISEASE IN CHILDHOOD

The problem presented by juvenile rheumatism is ofcourse entirely different. Here Lord Horder believesthe best hope lies in a national plan on the lines of theL.C.C. rheumatism scheme, which has helped to reducethe incidence of recorded heart disease in the L.C.C.

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school medical service from 2% in 1926 to 0-77% in 1926.This scheme provides supervisory centres to whichchildren suspected of rheumatic diseases are referred.Children who are fit for ordinary education return toschool but are kept under supervision ; those who needtreatment are referred to rheumatism units outsideLondon, and those cardiac cripples who can benefit byappropriate education (about 16%) are sent to specialschools. In a standard year there are usually about2000 children attending such schools.A similar scheme in its full range could be applied by

local -authorities to all state schools, and impoverishedareas should receive grants from national funds for thepurpose.

RESEARCH

There remains research : the most urgent need of all.For this the Empire Rheumatism Council is willing toassume responsibility, with what help can come from theMedical Research Council, the various medical researchfoundations and the medical schools. In addition, thetreatment centres, once in action, would become asource of statistics capable of answering many of thequestions still left teasingly open.

MEDICINE AND THE LAW

Aortic Disease an Accident

IN the case of Tyler v. New Hucknall Colliery,mentioned lately in this column, the Mansfield county-court judge held that the perforation of a duodenal ulcerwas not an accident within the Workmen’s CompensationAct. More recently, in Tennant v. Coppice Colliery Co.,the Walsall county-court judge decided in the workman’sfavour where a blow, received in the course of his work,was said to havd accelerated the disease of the aorta.The man worked for two days afterwards, stayed awayon the third day, gave up work after a brief attempt onthe fourth day and went to hospital where he wasX rayed. He died suddenly about a fortnight later.The pathologist who’ made a post-mortem examinationfor the purpose of the inquest gave evidence before thecounty-court judge which was consistent with the deathbeing in no way due to the blow. There was, said twomedical witnesses, a failure of the blood-supply in

consequence of the blocking of the arteries. Thecalcification of the aorta was exceptional ; the calcareousmatter had been accumulating over a long period and theaccident had no effect upon it. The judge, however,pointed out that the employers had been unable toexplain why the workman, having had nothing wrongwith him before the blow, had suffered pain after it.Drawing the inference that the accident had markedlyaccelerated the development of the condition of theaorta, he awarded ;E600 compensation..

Inadmissibility of Coroner’s VerdictIn Tennant’s case, mentioned above, the coroner’s

verdict had attributed death to the occlusion of the rightcoronary artery. The verdict of an inquest is, of course,of no value in other courts. This was clearly illustratedin the tragic case of Pollock v. Pollock this year. LastJune a devoted husband, worried and oppressed by thewar news, shot his wife and then shot himself. His wifehad left her estate to him, but the law does not allow amurderer (or anyone who claims through him) to profit’by his crime. The husband had killed his wife. If hewas insane at the time, it was not a murder; but theburden of proving insanity lay upon the husband’srepresentatives and, the husband being dead, they werenot likely to be able to discharge it. The wife’s executorsapplied to a Chancery judge for advice. They were toldthat they should act on the assumption that the husbandhad murdered his wife, and they should not hand thewife’s estate over to the husband’s representatives. Acoroner’s verdict had recorded that the husbandkilled his wife while his mind was unhinged ; but Mr.Justice Farwell was unfortunately prevented by lawfrom taking note of the facts determined by the inquest.

Workman’s Denial of Disease

A workman, on entering a mining company’s employ-ment, untruthfully made a written statement that he

had never suffered from nystagmus. The diseaseappeared and he qualified for compensation on thecertificate of the examining surgeon who fixed the dateof the disability. The company exercised its right tohave the workman examined by a surgeon to whom thepatient admitted that he had previously suffered fromnystagmus. This surgeon reported the disability to be asevere case and recorded the patient’s admission. TheWorkmen’s Compensation Act purports to disqualify aclaimant who has made a false denial on enteringemployment. The company nevertheless paid the mancompensation at the full rate until, many months later,payment was discontinued on the ground of the falserepresentation. What the Act says (in paragraph (b)of section 43 (1) ) is that " if it is proved that the work-man has, at the time of entering the employment,wilfully and falsely represented himself in writing as nothaving previously suffered from the disease, compensa-tion shall not be payable." The county-court judge heldthat there was false and wilful misrepresentation, but healso held that the paying and receiving of compensationformed a binding and concluded agreement between theparties and that all questions of liability were therebysettled. The Court of Appeal has upheld the countycourt. Section 43 (1) (b) is not an absolute prohibition.Those initial words " if it is proved " create an issue offact for an arbitrator to try. This issue can be thesubject of an agreement between the parties. If theemployers chose to pay compensation without availingthemselves of such precautionary safeguards as thelawyerlike words " without prejudice," and if theyoffered no explanation, their generosity was fatal.

SCOTLAND

POLISH MEDICAL FACULTY IN EDINBURGHTHE discussions which have been in progress between

the British and Polish governments and the universityand municipality of Edinburgh regarding the institutionof a Polish medical faculty in Edinburgh achieved theirend in the McEwan Hall of the University on March 22.Monsieur Wladyslaw Raczkiewicz, president of thePolish Republic, formally constituted the faculty andnamed its members. Sir Thomas Holland, vice-chancellor of the university, said that though warshad occurred in every century, countries had beeninvaded, and local institutions had been brought underthe control of conquerors, never before, since their risein the fourteenth century, had universities in any countrybeen ruthlessly destroyed. For precedent it was

necessary to go back another eight centuries to the timewhen the schools of the Roman Empire were sweptaway by other Teutonic savages, who by that meansinaugurated the Dark Ages. Among the first of theuniversities founded with the revival of learning was theJagiellonic University of Cracow which maintained itsreputation as a great home of liberal education for just540 years until, along with its sister universities, it waslately destroyed. The Polish universities had producedpoets and historians of great distinction, of whom,because of our linguistic limitations, we knew too little.But of those Poles who had published their works in theuniversal language of music, everyone knew of Chopinand Paderewski. The scientific and a wider world, too,revered the names of two famous Cracow graduates,Nicolaus Copernicus, whb in a double sense revolutionisedastronomy in the sixteenth century, and Marie Sklo-dowska, known to fame as Madame Curie. Round anucleus of a dozen professors and about fifty studentshe said, would grow a school of medicine so vigorous thatits Edinburgh cradle would barely be large enough to holdit until it was free to return again to its native land, thereto inaugurate a new era as the foundation faculty of therejuvenated Universities of Poland. Sir John Andersonconveyed to the new faculty the best wishes of theBritish Government ; in reply Professor Kot, the Polishminister of the interior, traced many academic associa-tions between Poland and Scotland in the past. Prof.Sydney Smith, dean of the faculty of medicine, alsowelcomed the newcomers. Professor Jurasz, the newlyappointed dean of the Polish faculty, looked forward toa time when they would all meet as free men, in free